Blood Transfusion

Dr Will Dooley

Plan

• Cases

• OSCE practice scenario

• Blood groups / Indications

• Monitoring / Reactions

CasesFor following cases: - Would you give them a blood transfusion? - How many units you would prescribe? - What other investigations/management would you consider?

1. Miss Irene Bleede, 23 yo asymptomatic, healthy woman with menorrhagia: Hb 84 g/l, MCV 73fl

2. Mr Oliver Negg, 86 yo asymptomatic man with occasional anginaHb 96 g/l, MCV 104fl

3. Mr Oscar Dere, 73 yo man presenting with acute upper GI bleedBP 80/60, Pulse 120 thready. Hb 82 g/dl, MCV 101fl

4. Mrs A Smith, 35yo woman post Caesarean Section, blood loss 2000mls. Seen on Day 1: obs stable. Dizzy on standing.Hb 66 g/dl (pre op 112)

3. Mr O Dere, 73 yo man presenting with acute/severe upper GI bleed

BP 80/60, Pulse 120 thready. Hb 82 g/l, MCV 101fl

Acute anaemia Mx: Stabilise (ABCDE) – involve senior /

emergency teamCross Match 4-6 units and

transfuseUrgent OGD

Ix: Clotting screen

4. Mrs A Smith, 35yo woman post Caesarean Section, blood loss 2000mls. Obs stable. Symptomatic Day 1 Hb 66 g/dl (pre op 101)

Acute anaemia from blood lossMx: Offer blood transfusion

Cases1. Miss I Bleede, 23 yo asymptomatic, healthy

woman with menorrhagiaHb 84 g/l, MCV 73fl

Microcytic anaemia Iron deficiencyMx: Oral iron replacement (e.g. Ferrous Sulphate)No transfusion requiredIx: Haematinics if not responding to iron replacement. Investigate menorrhagia if severe or resistant

2. Mr O Negg, 86 yo asymptomatic man with occasional angina

Hb 96 g/l, MCV 104fl

Macrocytic anaemia Mx: Treat causeIx: ?cause: B12 / Folate (megaloblastic) or alcoholic liver disease, hypothyroidism, acute blood loss (normoblastic)

Indications for Blood Transfusion

Acute Anaemia (rarely chronic anaemia)Symptomatic anaemia and blood lossPeri-operative: ‘replacing losses’Haemolysis (treat underlying cause)

Threshold of Hb? Hb < 70 g/L transfusion is usually indicated (NICE 2015)Hb < 80 g/L if acute coronary syndrome

Alternatives? Iron transfusion or Oral iron replacement

Blood products

Packed Red Cells1 unit raise haemoglobin by ~10-15g/l in 70kg patientNICE 2015: Restrictive transfusion (1 unit and aim for 70-90g/L post Hb)

Platelets For severe thrombocytopenia; consider if patient still actively bleeding1 unit raise platelets by 20x109

Same bedside checks and ABO/RhD checks as with red cells

Fresh Frozen Plasma (FFP)Contains all the coagulation factors

e.g. Disseminated Intracellular Coagulopathy

Whole blood Rarely used – components more valuable

Mrs Andrew Smith, 35yo woman post Caesarean Section, blood loss 2000mls.

Seen on day 1 post op:

Obs: HR 88 BP 125/89 RR 16 Sats 99% on air

Hb 66 g/dl (pre op 101) MCV 69fl

Management: Offer blood transfusion

OSCE Scenario

Transfusion discussion

1. Indication / Benefits

1. Risks (Inform patient that following a blood transfusion they can no longer be a blood donor)

2. Alternatives

3. How administered

4. Provide written information. Offer time to consider

5. Document discussion

Transfusion discussion

Chronic: Infections

Risk of HIV per unit transfused = 1 in 6 millionRisk of Hep B per unit transfused = 1 in 1.3 millionRisk of Hep C per unit transfused = 1 in 28 million

All tested for Hep B / Hep C / HIV 1&2 / Human T-cell lymphotropicvirus / syphilis +/- CMV and malaria

Risk = asymptomatic window period

Prescribing Blood

Prescribing Blood

Different at different Trusts – but principles the same

Usually on separate blood transfusion chart, prescribe:

“PACKED RED CELLS”

Timing: Needs to be complete in 4 hours (so logistically usually over 1-3 hours)

Same prescribing principles as with normal meds: Who? Sign/Print name/Contact numberWhen? Date/Time

Taking blood sample

Taking blood sample

Positive identification- Full name and DOBConfirm with ID wrist band and request form

Group and Save vs Cross Match

Write details on blood bottle after blood added and at bedside1. Who? Name/DOB/hospital number2. Where? Location3. When? Date/time4. Who?? Signature

Pre Transfusion Checks

1. IDENTIFICATION CHECKSa) Positive identification with TWO STAFF: Ask patient full name / DOBb) Check against wristband on the patientc) Check against compatibility label on blood unit / request form

2. BLOOD UNIT CHECKa) Check blood unit expiry date / number and blood groupb) Check blood bag: ensure free from clots / leaks

3. DOCUMENTATIONa) Record- blood pack number, date/time and signature of both staffb) Send request label back to lab to monitor completion

Pre Transfusion Checks

Pre Transfusion Checks – what to check

Putting up the blood

Putting up the blood

1. PRE CHECKSAseptic technique – wash hands, gloves, apronGiving set: Double lumen, check expiryPatient observations (baseline)

2. CONNECT BAGConnect the giving set to the blood bagSqueeze blood into both chambersPrime the giving set with bloodAttach to cannula

3. GO!Set drip rate

4. DOCUMENTRecord when started / by who / checks done

During procedure checks

When should observations be checked?Initial/baseline observations15 minutes after startingHourly thereafterAt end of transfusion

What should you be checking for? TemperatureHeart rate/Blood PressureRespiratory rate/Saturation

What symptoms should you be advising the patient to report?ANY!

Chest/Abdo painSOBRestlessness/anxietyRashBlood in urine

Checks during procedure

… Mrs Smith

Baseline observations: Temperature: 36.5Blood pressure: 120/80Heart rate: 80Saturations: 99% OA

15 mins into transfusionPatient c/o difficulty breathing

What would you do?

… Mrs Smith ...

Baseline observations: Temperature: 36.5Blood pressure: 120/80Heart rate: 80Saturations: 99% OA

15 mins into transfusionPatient c/o difficulty breathing

1. ABCDE AssessmentA- patent, B- wheeze throughout, C- well perfused, good cap refill

2. Consider stopping transfusion

3. Repeat ObservationsTemperature: 36.7Blood pressure: 105/70Heart rate: 90Saturations: 94% OA

Complications – which one?

Acute haemolytic reaction

TRALI

Infections

TACO

Anaphylaxis

Iron overload

Allergic rxn

Post-transfusion purpura

Fluid overload

Bacterial contamination

Graft vs host disease

Non-haemolytic febrile transfusion rxn

Complications – which one?

Acute haemolytic reaction

TRALI

Infections

TACO

Anaphylaxis

Iron overload

Allergic rxn

Post-transfusion purpura

Fluid overload

Bacterial contamination

Graft vs host disease

Non-haemolytic febrile transfusion rxn

When to stop the transfusion

Temperature - Increase by 1 degree

Blood Pressure - Significant change (+/- 10mmHg)

Heart Rate - Significant rise

Symptoms

Transfusion Reactions

General management:STOP Transfusion

Send blood product to labMaintain line with IV FluidCall for help

New FBC/U+E/Clotting samplesClear history of symptomsDocument

Think specifics for management

A Acute Haemolytic Transfusion

Reaction

B Allergic Reaction

C Anaphylaxis

D Bacterial Contamination

E Delayed Haemolytic Transfusion

Reaction

F Fluid overload

G Graft vs Host disease

H Haemolytic Disease of the Fetus and

Newborn (HDFN)

I Iron Overload

J Non-haemolytic Febrile Transfusion

Reaction

K Transfusion Associated Lung Injury

(TRALI)

1. 55yo complains of itching 20 mins into blood transfusion. Examination reveals urticaria over

his body.

2. 40yo intra-operatively becomes acutely hypotensive, tachycardic and pyrexial (38 degrees)

upon transfusion starting.

3. 50yo recieving a blood transfusion develops dyspnoea and a cough 3 hours later.

4. 30yo complains of chills but found to have temperature of 40 degrees and HR 105 after blood

transfusion with no other symptoms.

5. 65yo having blood transfusion in Togo hospital becomes acutely pyrexic (39ºC), hypotensive

with rigors.

A Acute Haemolytic Transfusion

Reaction

B Allergic Reaction

C Anaphylaxis

D Bacterial Contamination

E Delayed Haemolytic Transfusion

Reaction

F Fluid overload

G Graft vs Host disease

H Haemolytic Disease of the Fetus and

Newborn (HDFN)

I Iron Overload

J Non-haemolytic Febrile Transfusion

Reaction

K Transfusion Associated Lung Injury

(TRALI)

1. 55yo complains of itching 20 mins into blood transfusion. Examination reveals urticaria over

his body. B

2. 40yo intra-operatively becomes acutely hypotensive, tachycardic and pyrexial (38 degrees)

upon transfusion starting. A

3. 50yo recieving a blood transfusion develops dyspnoea and a cough 3 hours later. K

4. 30yo complains of chills but found to have temperature of 40 degrees and HR 105 after blood

transfusion with no other symptoms. J

5. 65yo having blood transfusion in Togo hospital becomes acutely pyrexic (39ºC), hypotensive

with rigors. D

Blood GroupsUNIVERSAL

DONORUNIVERSAL RECIPIENT

UK

Frequency42% 8% 3% 47%

Early vs. Delayed complications

Early (<24hrs)

Acute haemolytic reactionAnaphylaxisBacterial contaminationTRALI / TACONon-haemolytic febrile

transfusion rxnAllergic rxn

Late (>24hrs)

InfectionsIron overloadGraft vs host diseasePost-transfusion purpura

Early: Acute haemolytic reaction

e.g. ABO incompatibility – commonly clerical errors

Signs/symptoms: agitation, rapid onset fever, hypotension, flusing, abdominal/chest pain, DIC +/- death

LARGELY PREVENTABLECOMMONEST CAUSE = HUMAN ERROR

Acute Lung Complications TRALI vs. TACO

Signs/symptoms

Transfusion Related Acute Lung Injury

Dysponea, cough

General principles

Oxygen

Treat as ARDS

Transfusion Associated Circulatory Overload

Dysponea, hypoxia, tachycardia, creps+/- echo/BNP

General principlesOxygenDiuretic

Management

Acute: Other reactions

Non-haemolytic febrile transfusion reactionShivering and fever (1-1.5hrs post starting)Unpleasant but not life threateningMx: Consider anti-pyretic (paracetamol)

Bacterial ContaminationFever, hypotension and rigorsMx: Urgent septic screen, Broad spec ABx

AnaphylaxisBronchospasm, cyanosis, hypotension, soft tissue swellingMx: Maintain airway + Oxygen. Call help/2222

Allergic reactionUrticaria and itchMx: Chlorphenamine

Chronic: Other

Post Transfusion Purpura5-7 days post transfusionPlatelets fall – can be lethal

Graft-versus-host diseaseRare. Fatal.Donor lympocytes mount an immune response against the immunocompromised hostPrevented by irradiation of donor blood

Is blood transfusion necessary?

If so, ensure:

Right blood

Right patient

Right time

Right place

Summary

ANY QUESTIONS???

SMITH, Andrew01/10/19878765432

09/03/2017

SMITH, AndrewDOB: 01/10/1987Hospital Number: 8765432

21/02/2017

09/03/2017

SMITH, AndrewDOB: 01/10/1987Hospital Number: 8765432

21/02/2017

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